Basic Information
| Provider Information | |||||||||
| NPI: | 1265057822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CABEZAS DIAZ | ||||||||
| FirstName: | IVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11902 SW 180TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331772415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862863562 | ||||||||
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| Practice Location | |||||||||
| Address1: | 654 NE 9TH PL | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330304934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052483488 | ||||||||
| FaxNumber: | 3052486558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2020 | ||||||||
| LastUpdateDate: | 06/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-119155 | FL | Y |
No ID Information.